(see also emergency medicine, non-governmental organizations (NGO), and war)

Table of contents :

  • volcanic eruptions
  • storm
  • mass movements
  • earthquake
  • tidal wave
  • tsunami
  • wildfire
  • icebergs
  • cadaver management
  • disaster victim identification

  • Catastrophic events share characteristic nonlinear behaviors that are often generated by cross-scale interactions and feedbacks among system elements. These events result in surprises that cannot easily be predicted based on information obtained at a single scale. Progress on catastrophic events has focused on one of the following two areas: nonlinear dynamics through time without an explicit consideration of spatial connectivityor spatial connectivity and the spread of contagious processes without a consideration of cross-scale interactions and feedbacksref. These approaches rarely have ventured beyond traditional disciplinary boundaries. An interdisciplinary, conceptual, and general mathematical framework for understanding and forecasting nonlinear dynamics through time and across space has been proposed. Decisions that minimize the likelihood of catastrophic events must be based on cross-scale interactions, and such decisions will often be counterintuitive. Given the continuing challenges associated with global change, approaches that cross disciplinary boundaries to include interactions and feedbacks at multiple scales are needed to increase our ability to predict catastrophic events and develop strategies for minimizing their occurrence and impactsref.
    Dilley and colleagues at the World Bank broke down the most of the globe into 8 million grid cells of about 25 km2 each. They then mapped the risks of human and economic damage from 6 types of disaster, such as cyclones and landslides, on to each one and built up a picture of the world's most exposed placesref. The world's most vulnerable countries include Bangladesh, Nepal, Burundi, Haiti and Taiwan. In these places, > 90% of people are at 'high risk' of death for 2 or more types of disaster. The researchers define high-risk areas as having the top 30% of risk compared with other areas of the world. Although many of these areas were already known to be in danger, the report provides a more sophisticated way to compare risks across countries and regions, allowing governments and aid agencies to prioritize their resources. Much of the damage and death that disasters cause is preventable: by building earthquake-proof structures, for example. But repeated hits lock many of the world's developing countries into a cycle that makes it difficult to fund changes, especially as much aid goes into immediate relief efforts. The World Bank plans to use its hotspot map to identify those countries most in need and help them implement a preventive, rather than reactive, approach to disasters. Its approach is already affecting homeowners in Turkey, who must weather frequent earthquakes. When providing aid, the World Bank requires them to buy insurance for their homes. This shifts the responsibility for safe buildings from the government to the individual and private-sector insurance companies. The World Bank also intends to encourage governments to invest in measures such as flood embankments and cyclone shelters by granting loans to countries who plan for disasters. Countries have already started to request money specifically for risk management, indicating that the message is getting through. We must stop making it more complicated than it is : if you want to reduce problems after disasters, you just have to protect people by giving them better housing, better education and better health services.

    Natural catastrophes that can lead to loss of the ED itself are often overlooked in disaster plans and drills. Plans should address evacuation of patients, including transportation and equipment to take, and drills should include these scenarios. You should have alternatives to cope with loss of power and communications, such as oxygen-powered backup generators. To prepare for a deluge of individuals coming to the ED after a disaster, decide how to utilize volunteers, and limit access by using disaster identification vests. New Environment of Care standards from the Joint Commission on Accreditation of Healthcare Organizations require you to perform a hazard and vulnerability analysisref.

    Cadaver management : sometimes, natural or man-made disasters may mean that the normal disposal procedures cannot be followed. Under these circumstances, care must be taken to ensure that the disposal of human remains does not face an already stressed population with further risks. Ideally bodies should be cremated but if this is not possible burial with at least 1 metre of earth over the cadavers (to prevent access by scavengers and pests) is a satisfactory alternative. Religious and social practices should be followed as far as possible. Burial sites must be chosen so as to avoid the risks that water sources may be contaminated. The major hazard facing emergency service personnel is spilt blood and any risk can be greatly reduced by preventing contact with blood (use of gloves, face and eye protection, and protective clothing where necessary). Bodies that have been decaying for some time present little risk. The organisms likely to be present are their own body flora and water or environmental organisms. The use of proper protective clothing will protect personnel handling such material. Bodies should always be transported to mortuary facilities in waterproof body bags or cleanable, fluid retentive (e.g. fiberglass) temporary coffins. A report issued last September by the Pan American Health Organization (PAHO) addressed the management of dead bodies in disaster situations. Its findings suggest that the corpses from the 26 December catastrophe pose no serious risk of spreading infection and disease. Bodies should always be buried in a way that allows for later exhumation. The use of common graves should be avoided in all circumstances. The report calls mass burials "a violation of the human rights of the surviving family members". It is widely believed that swift burial is the only way to prevent the spread of diseases such as cholera. But that is a myth, the PAHO report reveals. Cholera does not appear spontaneously in the body of a person who did not have it to begin with. And although harmful bacteria or viruses in a corpse can in theory be spread by rats, flies, fleas and other animals, that doesn't tend to happen in practice. The temperature of a body falls rapidly after death, so even the most resistant bacteria and viruses die quickly in an animal that has died. Past experience shows that unburied dead bodies pose a negligible risk to those who do not come into physical contact with them. Handling of bodies by relief workers does, of course, require protective clothing. The report recommends that bodies be carefully reported and tagged before being placed in individual body bags. Changing beliefs about the need for mass graves will be a slow business. It took 2-3 decades for people in the Western world to understand that it is best not to move a person injured in a street accident, for example. To change ideas at a global level takes a lot of time. Therefore, the utmost priority from a public health point of view is not to bury all the dead immediately (which is what people on TV seem to be telling us), but to restore the safety of the water supply. In fact, for many of the affected countries, it is not a matter of "restoring" but establishing a safe source of water!!!  It will also be important to pay attention to environmental issues like vector control, waste disposal, and hygiene education.

    Disaster victim identification : when the devastating tsunami struck the Indian Ocean in December 2004, it was not DNA that identified most of the victims but traditional forensic methods such as comparing dental records. In Thailand, for example, DNA techniques put names to < 1% of the victims. The scale of the disaster made the detection effort particularly difficult. Teams were dealing with thousands of bodies in a hot, wet climate, where roads and other infrastructure had been destroyed and lab facilities were virtually non-existent. In other recent disasters, such as 9/11 and the massacres in the former Yugoslavia, DNA identification proved to be the most useful tool. But in Thailand neither the time nor the facilities were available. One advantage teeth have over DNA is that they can be stored. Without refrigeration DNA samples would have degraded. The public perception is that DNA would be the be-all and end-all of the identification process. To get 1500 identifications with DNA you would need to process as many as 8000 samples, because of the need to profile several relatives for each corpse. That is where the dentists came in. In Thailand some 75% of bodies were identified using dental records, 10% by fingerprints and just 0.5% using DNA profiling. For the remainder a combination of techniques was used. One advantage teeth have over DNA is that they can be easily stored to be compared with dental records later. Without refrigeration, DNA samples would have quickly degraded. Forensic odontologists were still working in Phuket months after the disaster. By February, they had identified > 400 people with dental records. By April > 1200 had been identified, and by July the number had reached 1700. The number identified by September is 2200, and 3300 bodies are unidentified. Dental records could not be found for all the Thai victims. In these cases the investigators made tentative identifications from photos of the victim smiling. The successes were achieved despite some foreign forensic teams' practice of concentrating on their own nationals. A few pathologists who spoke to New Scientist complained that teams from some countries sorted through the piles of bodies looking for their own citizens. Some foreign teams ignored the corpses of local victims. There were 1-2 who never reformed and genuinely couldn't or wouldn't acknowledge that they were doing anything wrong...They were parasitising on the rest of us. By contrast, Clement singles out the New Zealand team for praise. New Zealand only lost 3 people, yet their dental teams were there in numbers for a very long time helping everyone else quite selflessly
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    The headline concern for the tsunami victims, living and dead, will be with us for a few weeks; by contrast, their need for assistance and reform will stretch over decades. Huge sums have been pledged in aid and a bold commitment made to build an Indian Ocean tsunami warning system. But, if past is precedent, only a fraction of recent pledges will materialise and the already overdue warning system will remain a pipe dream for the affected communities. The headlines rightly applaud the compassionate outpouring of the public around the world but fail to question the logic of promoting one-off giving from individuals rather than sustained involvement by governments. Disasters are part of normality, and if we are to have a longlasting effect we need to rethink the way aid is delivered and invest in development to help minimise the effects of natural phenomena.
    The pledging of $5bn (£2.6bn, 3.8bn) for survivors of the tsunami only 3 weeks after the event, is an impressive expression of global concern. The track record of delivering on such commitments, however, is anything but reassuring
    amount pledged ($)
    amount delivered ($)
    Cambodian war rehabilatationref 880 m by June 1992  460m by 1995 
    Rwandan genocideref 707 m in January 1995  71m by July 1995
    Hurricane Mitch, central Americaref 9 bn in 1998  <4.5bn, December 2004 
    Bam earthquake, Iran (data from E Mansilla, Universad Nacional Autónoma de México) 1 bn in January 2004  116m December 2004
    Pledges fail to materialise for a host of reasons, some rational but some indefensible. Countries affected by disaster may have difficulty in absorbing huge aid flows quickly. Disasters destroy the infrastructure vital to delivering aid. Many of the civil servants, technicians, and local leaders who would normally carry out rehabilitation work may be killed in the disaster, as they were in the Rwandan genocide and the tsunami. Donors may attach conditions that make contributions difficult to use. These conditions may reflect a policy agenda (such as requiring the recipient country to respect human rights) or express a commercial objective (such as mandating purchase of goods and services from a given donor government). Funds pledged may pay for items that never quite make it into the disbursement ledger, such as the costs of military flights, shipping, and human resources for disaster response. Some of what gets counted as assistance actually takes the form of loans, further increasing poor countries' external debt. The dispassionate observer may be forgiven for wondering whether donors are motivated by the need to be viewed as pledging or by the desire to make a real difference in the lives and livelihoods of affected populations. The present funding and aid effort around the Indian Ocean is likely to meet most of the vital needs for survival. We should be less optimistic, however, about the medium and long term. The logic of disaster response tells us that funds should be pledged for identified needs. Needs are identified by local communities, affected governments, non-governmental organisations, and the UN. The UN produces, for most major disasters, a consolidated appeal that pulls together the needs identified by all its agencies in collaboration with the affected communities. The requests are, however, rarely met in fullref :
    Funds requested by UN for disasters and % not met, 2000-4
    Funds appealed for (total of all appeals in given year) ($bn)  1.9  2.6 4.4 5.2 3.4
    Average % of appeal not met 40.8 44.7 23.5 24.2 40.0
    The UN appeals are not wish lists; they represent real and immediate needs, and usually minimum needs at that. Any shortfall in funding should be seen as a failure on the part of the international community. Sadly, aid for long term needs rarely represents new money. Edward Clay, senior research associate at the Overseas Development Institute, London, noted immediately after the tsunami: "The research evidence is that the immediate response to natural disasters involves some new money, but that rehabilitation needs are often met by switching aid money between uses rather than increasing total aid to the countries affected."ref His speculation is proving correct. The United States has pledged $350m, and in early January had committed $44.6m of that to actual programmingref. Yet US Agency for International Development officials have acknowledged on national news programmes that these funds will come from existing aid budgets rather than new money. This means that those funds cannot now be spent on other priorities—for example, in Sudan or Bam. However, the US administration has so far resisted the suggestion that supplemental funding be sought to respond to the emergency. The present system of tallying aid flows distorts the apparent generosity of different parts of the world, playing up that of Western governments and playing down that of the general public and smaller nations of the world. The figures for funds pledged and spent usually derive from the UN's financial tracking system and, for historical data, from the Organisation for Economic Cooperation and Development's development assistance committee. These sources systematically underestimate global humanitarian giving. Public donations to non-governmental organisations are not reflected fully. Estimates suggest that Western nongovernmental organisations may raise as much as $2bn annually from the public. Analyst Abby Stoddard estimates that globally some 75% of the humanitarian resources of non-governmental organisations come from the general publicref. Funds from Islamic agencies and Islamic government to government funding also tend to be minimised in normal aid reporting. Another undercounted source is the considerable funding from diaspora groups around the world. In early 2001, after the earthquake in Gujarati, expatriate Gujaratis provided hundreds of millions of dollars above and beyond their normal remittances from overseasref. Finally the investment made by disaster survivors themselves in rebuilding their own communities is rarely calculated. One of the promising and noteworthy developments from the tsunami response has been the contributions from middle class people in India to relief efforts there and in neighbouring countriesref. On the government side, the first ever contribution by the government of China to an international relief mobilisation also bodes well for more inclusive and participatory international arrangements. The present system, however, will not necessarily capture these figures. The focus during the days after the tsunami, at least in the United States, has been on promoting private donations. The US president, joined by the past two presidents, has been appealing on television for citizens to dig deep and help out. Although the response from the American public has been overwhelming, such appeals hint at responsibility shifting. The emotional response to high profile suffering ensures a generous public response. That motivation, however, is insufficient as a source of funding for rehabilitation, prevention and reduction of future disasters, and tackling long term vulnerability. These more complex efforts should be seen as the common responsibility of states. Governments should not be allowed to shed this responsibility by appealing for private donations. Donor agencies reinforce the problem of longer term redevelopment by putting a premium on rapid disbursement of emergency funds. They have comparatively few funding lines available for rehabilitation and redevelopment activities. Redevelopment should include measures to mitigate the effects of a given disaster and to prepare to respond to the next disaster. In most development planning, however, disaster resilience, particularly for the poorest and most vulnerable communities, isn't on the agenda. Changes in approaches are needed that take people's livelihood strategies, knowledge, motivations, and other resources seriously, acknowledging the reality of disaster hazards and building disaster resilience into national development plans. Past experience suggests that little of the $5bn pledged for the tsunami is likely to go to the excellent but unheralded work of local non-governmental organisations that have been trying to provide increased security for the poorest households through microcredit, literacy training, and citizen based identification of hazards. An example of the small but high impact schemes that are often overlooked by major donors is provided by the US non-governmental organisation, Grassroots International, which has a partnership with the Sri Lankan union of small-scale fishermen to help repair and replace boats and nets. Disaster proofing also involves a great deal of risk judgment. What if the disaster never happens? Ninety per cent of all recorded tsunamis occur in the Pacific. Until now, governments have viewed the extension of the Pacifiic tsunami warning system (which has existed since 1949) into other ocean basins as a poor use of money on the basis of costs and benefits. This narrow view, however, ignores the possibility of merging cyclone and tsunami warning systems. Cyclones are much more common than tsunamis in the Indian Ocean, and a combined system would make sense. Geologists, seismologists, and tsunami experts have failed to interact with cyclone experts, and governments have been slow to take up their various suggestions. In 2003, an Australian geologist sought to get the UN's international coordination group for the tsunami warning system in the Pacific to include the Indian Ocean. In a decision that allowed governments to appear to be acting without really doing so, the group voted "to establish a sessional working group to prepare a recommendation to establish an intersessional working group that will study the establishment of a regional warning system for the southwest pacific and Indian Ocean.". Calls from Indian nongovernmental organisations for improvements in the warning system and the extension of cyclone warning to include tsunamis after the supercyclone disaster in Orissa state in 1999 were also ignored (K A Aryal, Disaster and Development Centre, Northumbria University, personal communication). When the smoke and mirrors clear, the minutes of such international groups reveal a timidity among governments unwilling to take the necessary preventive steps. We hope that the discussions on reducing natural disasters at the World Conference on Disaster Reduction in Kobe on 18-22 January ( will be animated by urgency and energy born of recent events. The global picture on natural disasters is changing. Data compiled by the Centre for Research on the Epidemiology of Disasters at Louvain University, Brussels, paints a disturbing picture. Over the past two decades, the annual deaths from disaster have fallen by around 30% whereas the number of people affected by disaster has gone up by 59%. The data also show that the number of disasters, almost all meteorological in nature, is steadily rising year on year, from an average of 150 a year in 1980 to over 450 a year today. Although some of this increase may be due to better reporting, a substantial part represents a very real phenomenon. Even more striking is the relation between development and disaster vulnerability. Analysng 2557 disasters between 1991 and 2000, the International Red Cross and Red Crescent Federation found that in countries with high human development indices there were 23 deaths per disaster, whereas in countries with low indices 1052 people died per disaster. In other words, development is an investment in disaster mitigation. The fall in deaths from disasters is partly explained by better warning systems and preparedness for predictable flooding. The data also signal the reluctance of governments to sustain high death tolls in disasters. In the past (for example, Ethiopia in the 1970s), high death rates in natural disasters have led directly to uprisings and the overthrow of regimes. Organised attempts to reduce death rates immediately after disasters have characterised relief work over the past 30 years. The rise in the number of people affected, and therefore the numbers needing to rebuild and facing future disasters, is concerning. The increase may reflect three factors. The first is climate change, which is producing more frequent extreme meteorological events and an inexorable rise in sea level. The second is the global trend of urbanisation, with most growth being in shantytowns and marginalised areas of cities and most large cities being located in coastal areas. Thirdly, the complexity of the development process tends to increase vulnerability to disaster. Miserable local and national governance (as seen in Haiti in last year's floods and landslides), debt policies, the structure of donor aid, the dynamics of population growth and forced displacement, and the growing effect of economic globalisation all have their effect. What is needed is a completely transformed arrangement for responding to large scale disasters. We propose a new system with three main features based on the premise that disasters are here to stay and will radically affect development. Firstly, UN relief agencies should be funded by assessed contributions from member countries rather than having to appeal for money after each disaster. UN peacekeeping operations, equally vital to saving lives, are already successfully funded on this basis. Such a funding mechanism would still leave room for governments to make supplementary voluntary payments, but it would also allow agencies to build reserve funds, to invest in training, and to act more quickly and save more lives. Secondly, the system for tracking humanitarian pledges, donations, and spending should be greatly refined and extended. It is morally inexcusable for pledges of funds to fade away as the cameras move on and for agreed rehabilitation and disaster proofing programmes to be halted, half funded. States and the global public need a financial tracking system that can trumpet when such abuses are taking place. The system also needs to be adapted to capture the funding provided by the public, which is often of the same order of magnitude as state funding. Thirdly, the mind set of economic development in areas prone to disaster needs to be radically changed. In northern countries, all new development programmes examine the risk from disaster and seek to protect infrastructure and economic processes from their worst effects. But in the south, where the economic costs of disaster are lower but human costs higher, no such attitude prevails. This is the most fundamental challenge. States, corporations, and donor agencies need to ensure that vulnerability to disaster is taken into account in economic development strategies and incorporate local knowledge and capacity for self protection. If they have the will to be successful, the next natural hazard could remain just that—a hazard but not a devastating disaster that compounds with profound vulnerability and leaves massive death and destruction in its wakeref. Inequity in the scale of response poses other problems. Over the past decade, about half of the $2bn (£1bn; 1.5bn) committed to the Inter Agency Standing Committee Consolidated Appeals went to high profile crises such as those occurring in Bosnia, Afghanistan, and Kosovo. Other countries affected by chronic conflict, such as Liberia and Somalia, received much less per person affected, although their needs are at least as great. Rapid onset disasters can also trigger a series of responses that are influenced more by emotions or political motives than by evidence based assessments of needsref. Some of these responses are harmful and can add to the suffering or chaos, such as rapid burials in mass graves because of unwarranted fear of epidemicsref. It is harder to raise funds for disaster prevention, preparedness, and mitigation than for response, even though there is strong evidence that response costs several times more to achieve the same effect. A dollar spent on constructing hospitals and houses to withstand natural hazards, such as hurricanes or floods, can save an estimated $5-7 on rebuilding after severe damageref. We agree with the authors' plea that funding arrangements should be revisited, but recognise that change will be incremental. We must make use of windows of opportunity for improvement, including learning from the tsunami experience. Donors are responding to criticism on inequitable funding allocations through the Good Humanitarian Donorship Initiative, in which they endorsed a set of principles and good practices to improve their role in humanitarian interventionsref. The initiative also commits to "strengthen the capacity of affected countries and local communities to prevent, prepare for, mitigate and respond to humanitarian crises, with the goal of ensuring that governments and local communities are better able to meet their responsibilities and co-ordinate effectively with humanitarian partners." The tragedy of 26 December 2004 is providing much evidence to support the rationale behind this goal. Thanks to strong institutions, and supported by civil society and non-governmental organisations, the national authorities of countries affected by the tsunami have been active in action and coordination for health since the first hours of relief. Within four weeks of the disaster occurring, the response is already shifting to rehabilitation. It is essential that available funds are also used for a long term strategy, to reduce the vulnerability to future disasters. Last week's world conference on disaster reduction in Kobe proposed that 10% of funds for responding to disasters be invested in strengthening preparednessref. Much expertise exists in this field, and programmes like the Leaders courses can enhance capacity to develop disaster reduction programmes by increasing strategic management, leadership, and analytical skills of the participantsref. Governments in Latin America now help their neighbours when they are hit by hurricanes and other natural disasters. Similar capacity is urgently needed in other parts of the world. Disasters undermine and reverse development, particularly in fragile states, where some indicators for the millennium development goals are in declineref. Adequate funding is needed to make progress and we should encourage donor countries to achieve the Monterrey consensus of providing 0.7% of their gross domestic product as development aid to the poorest countriesref. New ways must be found to coordinate and invest development and humanitarian funds in fragile states, so that communities at risk can receive adequate support to improve their livelihoods and reduce their vulnerabilitiesref.

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